Nobody Ever Gets Credit for Fixing Problems that Never ... · Total Quality Management (TQM). In...

Nobody Ever Gets Creditfor Fixing Problems thatNever Happened:CREATING AND SUSTAINING PROGESS

IMPROVEMENT

Nelson P. RepenningJohn D. Sterman

How much would your organization pay to develop manufacturingcapability equal to Toyota's? How much would a world-class, six-sigma quality program be worth to your company? How aboutHarley-Davidson's ability to tap into the hearts and minds of its cus-

tomers or Dell's ability to manage its supply chain? Most firms are workingaggressively to develop these and similar capabilities through process improve-ment. The combined expenditure of U.S. companies on management consul-tants and training in 1997 was over $100 billion, and a sizeable fraction wenttowards efforts to develop operational capabilities matching those of the bestfirms in business. Whether it's an advanced manufacturing system or the abilityto respond quickly to changing customer needs, the drive toward improvementhas become a way of life in corporations today. There is only one problem.Despite these vast expenditures, and notwithstanding dramatic successes in afew companies, few efforts to implement such programs actually produce signifi-cant results.

Consider, for example. Total Quality Management (TQM). In the 1980s,spurred by the success of many Japanese firms, TQM was all the rage amongU.S. firms. Consultants and business school faculty preached its virtues andmanagers made pilgrimages to companies with award-winning quality pro-grams. By the mid-1990s, however, TQM was considered passe. Academics hadmoved on to other issues, TQM received rare mention in the popular businesspress, and articles that did mention it usually did so in a negative context. TQM

Wark reported here was supported by the MIT Center for Innovation in Product Development underNSF Cooperative Agreement Number EEC-9529140. For more information on the research programthat generated this article, visit <http://web.mitedu/nelsonr/www/>.

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had all the earmarks of a management fad: An initial burst of enthusiasm, aflurry of aaivity, and then a steady decline as it was replaced by newer innova-tions such as re-engineering. It would be easy to conclude that TQM's underly-ing value was minimal.

However, when one looks at the experience a little more carefully, a dif-ferent picture emerges. A number of careful studies have now demonstrated thatcompanies making a serious commitment to the disciplines and methods associ-ated with TQM outperform their competitors.' There is now little doubt ihatwhen used properly. TQM produces significant value to both organizations andtheir customers. Yet paradoxically, it remains little used. A recent study foundthat fewer than 10% of the Fortune WOO had well-developed TQM programs;and, in another study, TQM fell from the third most commonly used businesstool in 1993 to 14'̂ in 1999.^ The situation is similar for a wide range of otheradministrative and technological innovations.' Techniques touted as today's*core competencies" all too often become tomorrow's failed programs. Oncean effort has failed, there is an almost irresistible temptation lo label it a fad or'flavor of the month." However, digging a little deeper shows that many suchtechniques have useful conteni. It should come as little surprise then that manycurrently popular innovations are little more than old ideas with new acronyms.The core disciplines associated with statistical process control and variancereduction become six-sigma; what was once called a quality circle is now ahigh-performance work team.

Thus, today's managers face a paradox. On the one hand, the number oftools and techniques available to improve performance is growing rapidly. Fur-ther, with advances in information technology and the ever-growing legions ofmanagement consultants, it is easier than ever to learn about these techniquesand to leam who else is using them. On the other hand, there has been littleimprovement in the ability of organizations to incorporate these innovations intheir everyday activities. The ability to identify and leam about new improvementmethods no longer presents a significant barrier to most managers. Instead, suc-cessfully implementing these innovations presents the biggest challenge. Put moresimply, you can't huy a turnkey six-sigma quality program. It must be developedfrom within.

To learn how firms can overcome this "improvement paradox," wehave, over the past decade, studied process improvement and learning programs,focusing on the dynamics of implementation and organizational change. Weconducted over a dozen in-depth case studies in industries including telecom-munications, semiconductors, chemicals, oil, automobiles, and recreationalproducts."* We gathered data through observations, extensive interviews withparticipants, archival records, and quantitative metrics. We complementedour field research with the development of a series of models capturing thedynamics of implementation and improvement.^ Using system dynamics as thebasis for understanding implementation has yielded a number of insights intothe improvement paradox. In at least some cases, these insights have proven

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insirumenta! in helping firms benefit from the potential provided by availableimprovement tools and techniques.

Most importantly, our research suggests that the inability of most organi-zations to reap the full benefit of these innovations has little to do with the spe-cific improvement tool they selea. Instead, the problem has its roots in howthe introduction of a new improvement program Interacts wilh the physical,economic, sodal, and psychological structures in which implementation takesplace. In other words, it's not just a tool problem, any more than it's a humanresources problem or a leadership problem. Instead it is a systemic problem, onethat is created by the interaction of tools, equipment, workers, and managers.

The Structure of Improvement

We present the lessons that have emerged from our study in the form ofa causal loop diagram. Our model provides both a useful framework for thinkingabout the challenges associated with implementing improvement programs andpractical suggestions to increase the chances that your next such effort will suc-ceed. While the theory reported here initially emerged from the study of twoimprovement initiatives in a major automaker," the resulting model is quite gen-eral and can be applied lo a range of situations. We have observed these dynam-ics in almost every organization we have studied.

Figure 1 begins with the basic "physics' underlying process improvement.The actual performance of any process depends on two faaors: the amount ofTime Spent Workintj and the Capability of the process used lo do that work. Forexample, in manufacturing, net usable output is given by the product of laborhours per day and productivity (usable units per labor hour).

The performance of any process can be increased by dedicating additionaleffort to either work or improvement. However, the two activities do not pro-duce equivalent results. Time spent on improving the capability of a processtypically yields the more enduring change. For example, boosting the workweek20% might increase output 20%, but only for the duration of the overtime.Gains in process capability, however, boost the output generated by every sub-sequent hour of effort. Similarly, overtime devoted lo reworking defective prod-uas can boost net usable output, but only as long as the overtime is continued,while eliminating the root causes of those defects permanently reduces the needfor rework. We capture this persistence by representing Capability as a stock(denoted by a rectangle), that is, as an asset thai accumulates improvementsover time. Specifically, Time Spent on Improvement increases the flow of Inwstmentsin Capability that augments process capability.

While it often yields the more permanent gain, time spent on improve-ment does not immediately improve performance. It takes time to uncover theroot causes of process problems and then lo discover, test, and implement solu-tions, shown in the diagram as a delay between improvement activities and the

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F IGURE I . The "Physics" of Improvement

DELAY

Investment inCapability

Time Spent onImprovement Time Spent

Working ActusIPerformance

IPerformance

Gap

tDesired

Performance

Note;Arrows indicate the dJrecLon of causality. Signs [ '+ 'or ' - ' ) at arrowheads indicate the polarity of reiationships: a'+'meaxis

that an increase in the independent variable aiuses the dependent v^iaWe to increase, all else being equal (a decrease causes a

decrease); similarly, a ' - ' indicates that an increase in the independent variable causes the dependent vanable to decrease (a

cfecrease causes an increase). For more deai!s, see J. Sterman, business Dynamics.' Systems Thinking and Modeling for a Comply World

(New York NY; Irwin/McGraw-Hill. 2000).

resulting change in process capability. Moreover, no improvement in capabilitylasts forever. Machines wear, processes go out of control without regular atten-tion, designs become obsolete, and procedures become outdated. Thus, we alsoshow an outflow from the stock capturing the inevitable decline of any capabil-ity that is not regularly maintained. The lag in enhancing capability depends onthe technical and organizational complexity of the process. Studies show thatthe delay in improving relatively simple processes such as the yield of machinesin a job shop is on the order of a few months, while the delay in improvinghighly complex processes such as product development can be several years ormore/ Similarly, the lifetime of improvements in capability will be shorter inorganizations with high rates of change in products and people.

Besides the physical and institutional structures that determine perfor-mance. Figure 1 also shows the goal for process throughput set by senior man-agers (labeled Desired Performance). The goal could be the number of produasdemanded by customers each day, the rate at which claims need to be processedby an insurance company, or the number of new products the firm seeks tolaunch this quarter. People compare that goal to their actual performance todetermine the Performance Gap. Not surprisingly, in the organizations we studied

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F IGURE 2. The Work Harder Balancing Loop


Time Spent onImprovement

Pressure toDo Work +

DesiredPerformance

Noie:The loop identifier, 31, tnd^cates a negative (balancing) feedback See J, Sterman, op. OL

it was rare to find a process performing above expectations. Instead, managers,workers, and engineers usually faced high and rising demands, sometimesdespite downsizing and cuts in resources. They were constantly searching forways to improve and close the performance gap. Since most organizations arereluctant to increase plant and equipment or hire more staff, managers hopingto close a performance gap have only two basic options.

First, they can try to increase the amount of time people actually spendworking. Figure 2 shows this option, which forms a balancing feedback, the WorkHarder loop BI. The process represented by this loop works as follows: Managersfacing a performance gap are under pressure to increase performance. Theypressure people to spend more time and energy doing work. An increase in thetime spent working increases the performance of the process and closes the per-formance gap. This structure is called a balancing feedback loop because it con-stantly works to balance desired and actual performance.

Pressure to do Work includes, most obviously, direa measures such astelling people to work faster or put in overtime, setting more aggressive targetsfor throughput, and imposing more severe penalties for missing those targets.Pressure also includes more subtle actions designed to extract greater effort fromemployees. These include the frequency with which performance is reviewed,the detail with which the reviews are conducted, and the seniority of thosedoing the reviewing. At one company we studied, it was not unusual for senior

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F IGURE 3. The Work Smarter Balancing Loop

GInvestment in

Capability

Time Spent onImprovemen

Work Smarter

Time SpentWorking

( V!!)V 'Work Har

ActualPerformance

]Pressure toDo Work +

PerformanceGap

Pressure toImprove

Capability

DesiredPerformance

vice-presidents to review the performance of individual machines on the factoryfloor. Not surprisingly, such attention sent a strong message to ali involved: keepthe machines busy at all costs. Similarly, a project manager we interviewedrecalled thai when a subsystem for which he was responsible Tell bebind sched-tjle, bis boss required him to call in every hour witb a status report until tbe pro-totype met its specifications.

A second option to close a performance gap is to improve the capability oftbe process. In Figure 3 we represent this option as another balancing feedbackprocess, tbe Work Smarter \Qo\i B2. Here, managers respond to a performanceshortfall by increasing the pressure on people to improve capability. They maylaunch improvement programs, encourage people to experiment with newideas, and invest in training. If successful, these investments will, with titne,yield improvements in process capability, boost throughput, and close the per-formance gap. Of course, everyone knows tbat it is better to work smarter tbanto work barder: An hour spent working produces an extra hour's worth of out-put, while an hour spent on improvement may improve the productivity ofevery subsequent hour dedicated to production. Yet, despite its obvious anddocumented benefits, working smarter does have limitations. First, as sbownin tbe diagram, tbere is often a substantial delay between investing in improve-ment activities and reaping the benefits. Further, the greater the complexity of

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the process, the longer it takes to improve/ Second, investments in capabilitycan be risky. Improvement efforts don't always find the root cause of defects,new tools sometimes don't produce the desired gains, and experiments oftenfail. While investments in capability might eventually yield large and enduringimprovements in productivity, they do little to solve the problems managers faceright now.

Thus, it is not surprising that managers frequently use the Work Harderloop to both accommodate variations in daily workload and solve pressing prob-lems created by unexpected breakdowns or defects. When a manufacturing lineserving an important customer goes down, a manager is unlikely to react bysending the work team to training in reliability improvement. Instead, thatmanager is going to get the line running and push for overtime until the ship-ment is out the door. Of course when the Une is back running and the producthas been shipped, the manager should retum attention to the improvementactivities that will prevent future breakdowns, and make up for the improve-ment time that was lost during the crunch. However, it doesn't usually happen.Instead, what we repeatedly observe, and what is more difficult to understand,are organizations in which working harder is not merely a means to deal withisolated incidents, but is instead standard operating procedure. Rather thanusing the work harder loop to occasionally offset daily variations in workload,managers, supervisors, and workers all come to rely constantly on workingharder to hit their targets and, consequently, never find the time to investin improvement activities. What starts as a temporary emphasis on workingharder quickly becomes routine.

The Reinvestment LoopTo understand why, it is helpful to consider how working smarter and

working harder are connected. The most important interconnection arisesbecause organizations rarely have excess resources. Increasing the pressure todo work leads people to spend less time on non-work related activities likebreaks and to put in overtime (that is, they use the Work Harder loop). Forknowledge workers such overtime is often unpaid and spills into nights andweekends, stealing time from family and community aaivities. There are, how-ever, obvious limits to long hours. Afier a while there is simply no more time.If the performance gap continues to rise, workers have no choice but to reducethe time they spend on improvement as they strive to meet their ever-increasingobjectives. Figure 4 adds the conneaion between pressure to do work and theamount of time spent on improvement.

The additional link creates the Reinvestment loop. Unlike those describedso far, the Reinvestment loop is a positive feedback that tends to reinforce which-ever behavior currently dominates. An organization that successfully improvesits process capability will experience rising performance. As the performancegap falls, workers have even more time to devote to improvement, creating avirtuous cycle of improved capability and increasing attention to improvement.

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F I G U R E 4 . The Reinvestmerit Reinforcing Loop



Time SpentWorking Actual

Performance

Work HarderI


PerformanceGap

Work Smarter

Pressure toImprove

Capability

DesiredPerformance

Note:The loop identifier. R l . indicates a positive (reinforcing) feedback. See J. Sterman, op. a t

Conversely, if managers respond to a throughput gap by increasing work pres-sure, employees increase the amount of time spent working and cut the timespent on improvement. Capability begins to decay. As capability erodes, the per-formance gap grows still more, forcing a further shift towards working harderand away from improvement. Here the reinvestment loop operates as a viciouscycle, driving the organization to ever-higher degrees of work pressure and min-imal levels of process capability. Not surprisingly, such a vicious cycle quicklydrives out meaningful improvement activity. Here, for example, is the way amanager in an electronics assembly plant explained the persistent failure of theorganization to engage in process improvement:

"Supervisors never had time to make improvements or do preventative mainte-nance on their lines . . . they had lo spend all their time just trying to keep theline going, hut this meant it was always in a state of flux, which, in turn, causedthem to want to hold lots of protective inventory, because everything was sounpredictable. A quality problem might not be discovered until we had produceda pile of defective parts. This of course meant we didn't have time to figure outwhy the problem happened in the first place, since we were now really behindour produaion schedule. It was a kind of snowball effea that just kept gettingworse."



Shortcuts and the Capability Trap

The Reinvestment loop means a temporary emphasis on one option at theexpense of the other is likely to be reinforced and eventually become perma-nent. Organizations that invest in improvement will experience increasing capa-bility and find that they have more time to allocate to working smarter and lessneed for heroic efforts to solve problems by working harder. In the successfulinitiatives we studied, leadership often worked to strengthen the reinvestmentprocess by explicitly allocating the resources freed up by productivity gains tofurther improvement. Unfortunately, however, these initiatives were the excep-tion rather than the rule. In most of the organizations in our study the reinvest-ment loop worked as a vicious cycle and prevented improvement programs fromgetting off the ground. Even when improvement programs yielded initial results,cost and schedule pressures soon tempted many organizations into downsizingor higher performance goals that drained resources away from improvement,weakening the reinvestment loop and causing capability to stall or even fall'

Understanding why the reinvestment loop typically worked in the down-ward, vicious direction rather than the upward, virtuous direction requires thatwe add a final link to the model (see Figure 5). As discussed above, cuttinginvestments in maintenance and improvement in favor of working hardererodes process capability and hurts performance. However, capability does notdrop right away. It takes lime for process integrity to depreciate. In the mean-time, the decision to skimp on improvement—skipping improvement teammeetings, neglecting to take machines down for scheduled maintenance, orignoring documentation requirements—boosts the time available to get workdone right now. We capture this interconneaion by adding a negative linkbetween Time Spent on Improvement and Time Spent Working. When the perfor-mance gap rises and managers resort to increased work pressure, overworkedpeople cut back improvement activity to free still more time for production. Theperformance gap falls, closing a third feedback that works to balance desired andactual performance. We label this the Shortcuts loop (B3) to capture the idea thatincreased throughput comes at the cost of departing from standard routines andprocesses, cutting corners, and reducing the time spent on learning andimprovement.

Shortcuts are tempting because there is often a substantial delay betweencutting corners and the consequent decline in capability. For example, supervi-sors who defer preventive maintenance often experience a "grace period" inwhich they reap the benefits of increased output (by avoiding scheduled down-time) and save on maintenance costs. Only later, as equipment ages and wearsdo they begin to experience lower yields and lower uptimes (see section 4). Sim-ilarly, a software engineer who forgoes documentation in favor of completing aproject on time incurs few immediate costs; only later, when she returns to fixbugs discovered in testing does she feel the full impact of a decision made weeksor months earlier.'" Thus, the Shortcuts loop is effective in closing the throughput

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F I G U R E 5. The Shortcuts Balancing Loop

^ ^ Time SpentWorking


ActualPerformance

Work Harder1


PerformanceGap

Work Smarter

Pressure to "*•Improve

Capability

DesiredPerformance

gap only because capability does not change immediately when the time dedi-cated to learning and improvement declines.

To illustrate these dynamics. Figure 6 shows two simulations of the modelin which we show how a hypothetical process reacts to working harder versusworking smarter. Both simulations begin in the same equilibrium state. The firstsimulation shows the response to an increased emphasis on working harder. Asmore effort is dedicated to work, gross throughput immediately rises. Time spentimproving falls immediately, but capability does not. Performance thereforerises. The benefit of working harder is, however, short-lived. With less timedevoted to improvement, capability gradually erodes, eventually more thanoffsetting the increased time spent working. Working harder creates a "better-before-worse" situation. Conversely, as seen in the second simulation, increasingthe time spent on improvement reduces output in the short run. Eventually,however, capability rises more than enough to offset the drop in work effortand performance is permanently higher, a "worse-before-better" dynamic.

The interaction between the balancing Shortcuts loop and the reinforcingreinvestment loop creates a phenomenon we call the Capability Trap and helpsexplain why organizations often find themselves stuck in a vidous cycle of de-clining capability. Managers and workers in need of an immediate performance

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F IGURE 6. Simulations oftheWorking Harder andWorking Smarter Strategies

SYSTEM RESPONSE TO:

WORKING HARDER

Actual Performance

Time

Effort

Time Spent Improving

Time Spent Working

Time

Time

WORKING SMARTER

Actual Performance

Time

Effort

Time Spent Improving

Time Spent Working

Time

Time

boost can gel it by skimping on improvement and maintenance. However, capa-bility eventually declines, causing the Reinvestment loop to work as a viciouscycle. Managers who rely on working harder and shortcuts to meet immediatethroughput needs soon find the process falling short of its objectives, requiring afurther shift towards working harder and away from improvement. To see thecapability trap in action, consider how a manufaauring supervisor in an auto

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company explained the Inability of her organization to make a commitment toregular improvement aaivities:

"In the minds of the [operations team leaders] they had to hit their pack counts.This meant if you were havitig a bad day and your yield had fallen . . . you hadto run like crazy to hii your target. You could say. 'you are making 20% garbage,stop ihe line and fix the problem,' and they would say. '1 can't hit my pack countwithout running like crazy.' They could never get ahead of the game."

By keeping the line going rather than stopping to fix the problem, these teamleaders relied on the Shortcuts loop to hit their throughput objectives. However,by "running like crazy" they also caused the Reinvestment loop to operate as avicious cycle, driving the line to a minimal level of capability and forcing themto run ever faster.

The capability trap is not limited to manufacturing—we have observedit in firms ranging frotn financial services to construction. For example, thecapability trap prevented a product development organization we studied fromdeveloping new processes that would have increased productivity. Like manyfirms, they sought to create an engineering library or "bookshelf of reusabledesigns and software. However, as described by an engineering manager.

"An engineer might nol take the time to document her steps or put the results ofa simulation on the bookshelf and because of thai she saved engineering time anddid her projeci more efficiently. But in the long run it prevented us from beingable to deploy the reusability concepts that we were looking for."

Just as machine operators and supervisors in the first example faced a basictrade-off between producing and improving, development engineers were forcedto trade off getting their assigned tasks done against documenting what theylearned so that others might benefit. Engineers could make more rapid progresstowards their objectives by taking shortcuts and ignoring the bookshelf, butdoing so prevented them from initiating the self-reinforcing reinvestment loopthat wotild have led to improved process capability.

The Persistence of the Capability Trap

Because working harder and taking shortcuts produce more immediategains and help solve today's problems, managers unaware of the inherent"better before worse" trade-off are likely to choose them over working smarter.Unfortunately, these temporary gains come at the expense of the long-runhealth of the process. By pressuring people to work harder, managers often un-wittingly force their organizations into tbe capability trap where ever-increasinglevels of effort are required to maintain performance. Of course, this phenome-non is not limited to large organizations. Many readers will recognize thisdynamic in different aspects of their personal lives. In situations ranging fromlearning how to use a new software package to committing to a new exercise

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program, we often fail to do the things that will improve our long-run produc-tivity and well-being due to the short-run stresses of other obligations.

A question naturally arising at this point is: "Wouldn't managers eventu-ally figure this out?" While it is understandable that, on occasion, people getcaught in the capability trap, wouldn't they eventually realize the true source oftheir problems and rebalance their efforts between working harder and workingsmarter? Unfortunately, the data suggest that overcoming the capability trap israre. Managers often do not realize how deeply they are trapped in it. Instead,the lessons that people learn when caught in the capability trap often lead toactions that make the situation worse.

Faulty AttributionsSuppose you are a manager faced with inadequate performance. Your

operation is not meeting its objectives and you have to do something about it.As we have outlined so far, you have two basic choices: get people to workharder or get them to work smarter. To decide, you have to make a judgmentabout the cause of the low performance. If you believe the system is underper-forming due to low capability, then you should focus on working smarter. If, onthe other hand, you think that your workers or engineers are a little lazy, undis-ciplined, or just shirking, you need to get them to work harder.

How do you decide? Research suggests that people generally assumethat cause and effect are closely related in time and space: To explain a puzzlingevent, we look for another recent, nearby event that might have triggered it.People also tend to assume each event has a single cause, underestimate timedelays, and fail to account for feedback processes. How do these causal attribu-tions play out in a work setting? Consider a manager observing a machine oper-ator who is producing an unusually high number of defects. The manager islikely to assume that the worker is at fault: The worker is close in space and timeto the production of defects, and other operators have lower defect rates. Thetrue cause, however, may be distant in space and time from the defeas it cre-ates. Perhaps the defect is actually the result of an inadequate maintenanceprocedure or the poor quality of the training program. In this case, the delaybetween the true cause and the defective output is long, variable, and oftenunobservable. As a result, managers are likely to conclude that the cause of lowthroughput is inadequate worker effort or insufficient discipline, rather thanfeatures of the process. The attribution of a problem to the characteristics—andcharacter flaws—of individuals in a system rather than to the system in whichthey find themselves is so pervasive that psychologists call it the "fundamentalattribution error.""

Suppose managers conclude that people, not the process, are the sourceof low performance. Having made such an attribution it makes sense to increaseproduction pressure. As discussed above, an increase in production pressurehas two effects. Worker effort immediately rises, closing the performance gapas the manager intended. However, workers are now less able to achieve their


Nobody Ever Gets Credit for Frxing Problems that Never Happened

objectives by increasing the time they spend working. To continue to hit theirever-increasing targets, they eventually resort to shortcuts, cutting the timespent on improvement. However, as highlighted above, the Shortatts loop, whilehaving the desired effect in the short run, yields a long-run side effect. With lesseffort dedicated to improvement, capability begins to decline. Performance falls,offsetting the initial gains. By continually increasing throughput objeaives inthe pursuit of better performance, managers who mistakenly attribute low per-formance to the attitudes and dispositions of their workforce inadvertently forcethe system into the capability trap.

Superstitious LearningThe bias towards blaming people rather than the system in which those

people are embedded means managers are prone to push their organizationsinto the capability trap. As workers spend more and more of their time onthroughput and cut back on fundamental improvement, shouldn't managersrealize that the true cause of sub-standard performance is low process capabilityrather than unmotivated workers? Unfortunately, in many situations managerslearn the opposite lesson.

Managers cannot observe all the activities of the workers. Hence, afterthey apply production pressure, they cannot easily determine how much ofthe resulting rise in throughput is due to increased work effort (the Work Harderloop) and how much to cutting back on training, improvement or maintenance(the Shortcuts loop). For example, suppose there is a performance gap requiringan additional six hours of productive effort per person per week. Managers,believing employees are simply not working hard enough, increase productionpressure. Workers buckle down, cutting back on breaks, web-surfing and othernonproductive time. Suppose these responses yield only two hours per personper week. To close the remaining throughput gap, workers resort to shortcutsand gradually reduce the time they spend on process improvement, training,and experimentation until they free the needed four hours per week. Managersobserve that throughput rises by the equivalent of six hours of productive effort.

Because managers do not fully observe the reduction in training, experi-mentation, and improvement effort (they fail to account for the Shortcuts loop),they overestimate the impact of their get-tough policy, in our example by asmuch as a factor of three. The feedback managers receive does not correct theerror. To the contrary, managers quickly learn that boosting production pressureworks—throughput rose when they turned up the pressure. The gains resultingfrom production pressure provide powerful evidence confirming their suspicionsthat workers were not giving their full effort.

We call this syndrome the Self-Confirming Attribution Error. Once managersdecide that the workforce is the source of their difficulties, they take actionsthat provide convincing and immediate evidence confirming this erroneousattribution. The cycle of self-confirming attributions drives the organization tohigher levels of produaion pressure and fewer resources dedicated to process

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improvement. Far more importantly, however, it gradually changes the mentalmodels of the managers by providing them with increasingly compelling evi-dence that the source of low throughput can be found in the poor attitudes andweak character of the workforce. Recall the project manager discussed abovewho was required to provide hourly status reports on a balky prototype. Soonafterward the problem was solved, confirming the boss's belief that he had actedappropriately, indeed had decisively taken charge of the situation, even thoughthe team was already working around the clock and his interference drainedprecious time from iheir efforts to solve the problem.

More subtly, the long-run efferts of production pressure also reinforcemanagers' belief that workers are the problem. The delay between increasedproduction pressure and increased throughput (via the Work Harder and Shortcutsloops) is short, and the connection between work effort and output is unam-biguous. In contrast, the erosion of process capability caused by produaionpressure is delayed, gradual, and diffuse. It is distant in time and space from itscause. Managers are unlikely to attribute the cause of a throughput gap lo thepressure they placed on workers months or even years before. Instead, theyare likely to conclude that the workers have once again slacked off, requiringanother increase in produaion pressure.

Workers often unwittingly conspire in strengthening the managers' attri-butions. Faced with Intense production pressure, people are naturally reluctantto tell supervisors they can't meet all their objectives. The more effectively work-ers cover up the shortcuts they take to meet their throughput targets, the lessaware managers will be of the long-run costs of production pressure. Unawarethat improvement activity, maintenance, and problem solving have been cut,throughput appears to rise without requiring any sacrifices, reinforcing manage-ment's attribution that the workers really were not working hard enough. Whenmanagers eventually discover these shortcuts, their view of workers as untrust-worthy is confirmed. Managers are then, as they see it. forced to monitor workereffon even more closely (e.g., more frequent status reports, stiffer penalties formissing targets, software for monitoring key-stroke rates of data entry opera-tors). What starts as an erroneous attribution about the skills, effort, and char-aaer of the workers becomes true. Managers' worst (ears are realized as aconsequence of their own actions.

Consistent with our theory, we are not attributing these dynamics tounskilled, inexperienced, or ill-intentioned managers. Rather, the structure ofthe system inadvertently leads even many talented and dedicated managers intothe capability trap, while at the same time providing compelling evidence thatthe sources of their difficulties lie in factors beyond their control, such as lazyworkers, a "difficult" union, faulty machinery, or fickle customers. Managers areunlikely to escape the capability trap because they rarely realize they are in it.Instead, as capability stagnates despite repeated attempts at improvement, theyslowly, perhaps reluctantly, but with increasing conviction, come to believethat their problems lie in the attitudes and diaracter of the people that work for

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them. Having made such an attribution, the actions they take, while rationalfrom their perspective, make the situation worse.

How Superstitious Learning Thwarts Improvement Programs

What happens when an organization stuck in the capability trap attemptsto implement an improvement program? Performance is low and work pressureintense. In such environments, improvement programs add to the workload—the organization is so far behind that it cannot afford to cut back throughput.Indeed, in many organizations, management imposes aggressive stretch objec-tives for both throughput and improvement in the belief that aggressive goalsare needed to shake things up and motivate people. In one firm we studied,the general manager laid out his goals for improving the product developmentprocess by saying:

"We need a development process that is fast, is the besl in the industry, and itneeds to increase throughput by 50% in two years. And everyone must adhereto the same process."

At the same time, they launched many new development projects inanticipation ol the expected productivity gains. Viewed through the lens of man-agement's mental model these decisions were entirely rational. However, thatmental model, conditioned by the self-confirming attribution error dynamicsdiscussed above, led them to the erroneous belief that the delay betweenimprovement effort and results was short and that their engineers were under-utilized, undisciplined, unmotivated, and unwilling to adhere to the specifiedprocess.

The company spent millions and invested countless person-hours tocreate a new product development process. The new process included bettertechnical tools, such as improved CAD/CAE/CAM systems, but also increasedmonitoring, including a structured stage-gate review process and mandated useof project management software. While there were some pockets of success, inmost cases the effort had little impact. The leaders of the change effort oftenattributed its failure to the engineers' lack of discipline:

"Engineers—by trade, definition, and training—want to forever tweak things.It's a Wild West culture."—Manager A

"We weni through a period where we had so little discipline that we really hadthe 'process du jour.' Get the Job done and how you did it was up to you."—Manager B

"A lot of the engineers felt that Ithe new process] was no value-add and thatthey should have spent all their time doing engineering and not filling out projectworksheets. It's brushed off as bureaucratic."—Manager A

"It was fair to say that a lot of engineers viewed this as a neat way lo get somefancy tools and to hell with process."—Manager C


Nobody Ever Gets Credtt for Rxing Problems that Never Happened

Yet, when we asked engineers why the effort failed, we got a differentstory:

'We never had time to take the courses and get the equipment we needed toreally make this stuff work. . . . It was really exhausting trying to leam how touse ihe tools and do the design at the same time. "—Engineer A

'People had to do their normal work as well as [use the new project managementsystem]. There just weren't enough hours in the day, and the work wasn't goingto wait."—Engineer B

"Under this system . . . the new workload was alt increase. . . . In some cases yourworkload could have doubled."—Engineer C

"How did we catch up? We stayed late. Most of ihe team was working from 7:00a.m. to 8:00 p.m. and on weekends. A lot of people worked right through theChristmas vacation."—Engineer D

"The new process is a good one. Someday I'd like to work on a project that actu-ally uses it.'—Engineer E

While managers felt the engineers had little interest in following theprocess, engineers became increasingly frustrated with leaders they felt had nounderstanding of what was really required to develop new produas. Faced withthe double bind of hitting aggressive performance targets and equally aggressiveimprovement targets, they were forced to cut corners while still appearing tofollow the process. As one engineer remarked,

"In many ways we worked around the [new] system. Good, bad, or indifferentthat's what happened. We had a due date and we did whatever it took to hit it."

As management discovers the engineers' shortcuts and workarounds, their viewthat the engineers can't be trusted is confirmed, and they are forced to step uptheir monitoring. Faced with similar difficulties in its effort to implement a newproduct development process, a different firm even created a cadre of "compli-ance managers" whose sole job was to enforce adherence to their new develop-ment process.

Workers in such organizations quickly learn to hide problems from oth-ers. In all of the organizations we studied, engineers routinely negleaed toreveal the existence of serious design issues for fear of retribution from man-agers. In one firm, the motto of the development engineers was "never revealyou have a problem until you also have the solution." In another, engineerscalled the weekly progress review meetings the "liars' dub"—each participantoverstated the progress of his subsystem and hid known defects from others inthe hope that others would be discovered first, giving them time to catch up.'^The consequence is long delays in the discovery of needed rework, greatlyincreasing costs, delaying launch, and, often, compromising quality.

The capability trap goes beyond low capability and high work pressure.Eventually it gets embedded in deeper structures, including incentives and

80 CALIFORNIA MANAGEMENT REVIEW VOL 43, NO. 4 SUMMER 200!

Nobody Ever Gets Credit for Rxing Problems that Newr Happened

corporate culture. As organizations grow more dependent on firefighting andworking harder to solve problems caused by low process capability, they rewardand promote those who, through heroic efforts, manage to save troubled pro-jects or keep the line running. Consequently, most organizations reward last-minute problem solving over the learning, training, and improvement activitiesthat prevent such crises in the first place. As an engineer at an auto companytold us, "Nobody ever gets credit for fixing problems that never happened." Overtime, senior management will increasingly consist of these war heroes, who arelikely to groom and favor other can-do people like themselves. As described bya project leader we interviewed,

"Our [company] culture rewards the beroes. Frankly, tbat's bow I got wbereI've gotten. I've delivered programs under duress and difficult situations andthe reward tbat comes witb that is that you are recognized as someone that candeliver. Those are tbe opportunities for advancemem."

Thus incentives and culture not only reinforce the tendency toward short-runthinking and working harder, but also are themselves shaped by that very short-term focus and work-harder mentality, creating another reinforcing feedbackthat intensifies the capability trap."

An organization suffering from the self-confirming attribution error ispoorly positioned to escape the capability trap. Improvement programs addstress to the organization, triggering greater work pressure that prevents peoplefrom investing in improvement, and encourages shortcuts. In such organizationsmany improvement programs never get off the ground. If, despite the workpressure, people do succeed in allocating more time to improvement, the resultis a short-term drop in performance as time spent working falls before theinvestments in improvement bear fruit. Observing that performance is notimproving, managers conclude the particular improvement method is not work-ing and abandon it. Since the need to improve remains, they search for another,more promising tool, only to find it too suffers a similar fate. The result is grow-ing cynicism among employees about 'flavor of the month" programs.

More insidiously, these dynamics strengthen stereotypes and conflictsthat not only hurt organizational performance but damage society. Consider,for example, how a senior manager explained why the product developmentimprovement effort he ran had failed:

"Program management and tbe disdpUnes associated witb it continue to be aproblem in my opinion in most western cultures. The people that are particularlyrigorous and disciplined, the Japanese and the Germans, tend to be so by culturalnorms. I can't tell you if it's bereditary or society or where it is they get it but thebest engineers are those that tend to be the most disciplined, not as individualcontributors but as team-based engineers. So there's a strong push back from thewestern type of engineer for much of this."

There is no mention of the struaural features of the system or the pres-sure, felt throughout the organization, to deliver ambitious projeas on time.

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Nobody Ever Gets Credit for Frxing Problems that Never Happened

Instead, this manager blames the failure on the undisciplined character of"Western" engineers. Such attributions, here generalized to entire nationalgroups, and invoking a disturbing racial and ethnic subtext, are typical of thefundamental attribution error. As these attributions are shared and repeatedthey become institutionalized. They become part of the corporate culture, and,as suggested by the quote above, can strengthen pernicious stereotypes and prej-udices in society at large.

Overcoming the Capability Trap

So what can be done? The most important implication of our analysisis that our experiences often teach us exactly the wrong lessons about how tomaintain and improve the long-term health of the systems in which we workand live. Successful improvement must include a significant shift in the mentalmodels of those both leading and paaicipating in an improvement effort. Thisinsight was captured succinctly by one manager in a successful improvementeffon:

"There are two theories. One says, 'there's a problem, let's fix it.' The other says'we have a problem, someone is screwing up, let's go beat them up.' To makeimpruvemem, we aniki no longer embrace the second theory, we had lo usethe Hrst."

Once the cycle of self-confirming attributions is broken, any number of processimprovement tools and methods can help improve capability. Without this shift,new tools and techniques, no matter how great their potential, are unlikely tosucceed.

Breaking the cycle of self-con firming attributions is not easy, but it canbe done. The following are examples from two organizations that overcamethese difficulties and introduced successful improvement efforts.'**

Du Pont

In 1991, an in-house benchmarking study documented a gap betweenDu Pont's maintenance record and those of the best performing companies inthe chemicals industry. The benchmarking study revealed an apparent paradox:Du Pont spent more on maintenance than industry leaders but got less for it.Du Pont had the highest number of maintenance employees per dollar of plantvalue, yet its mechanics worked more overtime. Spare parts inventories wereexcessive, yet they relied heavily on costly expedited procurement of criticalcomponents. Overall, Du Pom spent 10-30% more on maintenance per dollarof plant value than ihe industry leaders, while overall plant uptime was some10-15% lower.

An experienced manager, Winston Ledet, and a team charged withimproving maintenance operations, developed a system dynamics model ofthese issues. The modeling process involved extensive hands-on workshops in

82 CAUFORNIA MANAGEMENT REVIEW VOL43.NO,4 SUMMER2001


which the team, assisted by an experienced modeler, discussed, tested, andchanged the model as they identified areas needing improvement. Using themodel as a laboratory to design and test different policies, the team graduallydeveloped an appreciation for the capability trap and the paradox of high main-tenance costs and low reliability.

To see how the capability trap arose in the chemicals industry, imaginethe effects of cost cuts on maintenance, such as those beginning with the oilcrisis of 1973 and subsequent recession. In chemical plants, when critical equip-ment breaks down, it must be fixed. Hence maintenance managers requiredto reduce costs must cut preventive maintenance, training, and investments inequipment upgrades. The drop in planned maintenance eventually causesbreakdowns to increase, forcing management to reassign more mechanics fromplanned maintenance to repair work. Breakdowns then rise even more. Asuptime falls, operators find it harder to meet demand and become less willing totake equipment down for scheduled maintenance, leading to more breakdownsand still lower uptime. More breakdowns simultaneously constrain revenue (bylowering production) and increase costs (due to overtime, expedited parts pro-curement, the nonroutine and often hazardous nature of outages, collateraldamage, and so forth). More subtly, lower uptime erodes a plant's ability to meetits delivery commitments. As it develops a reputation for poor delivery reliabil-ity, business volume and margins fall further. The plant slowly slides into thecapability trap, with high breakdowns, low uptime, and high costs.

Policy analysis showed that escaping the capahility trap necessarily meantperformance would deteriorate before it could improve; While continuing torepair breakdowns, the organization has to invest additional resources inplanned maintenance, training and part quality, raising costs. Most importantly,increasing planned maintenance reduces uptime in the short run because opera-ble equipment must be taken off-line for the planned maintenance to be done.Only later, as the Reinvestment loop begins to work in the virtuous direction, doesthe breakdown rate drop. Fewer unplanned breakdowns give mechanics moretime for planned maintenance. As maintenance expenses drop the savings canbe reinvested in training, parts quality, reliability engineering, planning andscheduling systems, and other aaivities that further reduce breakdowns. Forexample, upgrading to a more durable pump seal improves reliability, allowingmaintenance intervals to be lengthened and inventories of rejilacement seals tobe cut. Higher uptime also yields more revenue and provides additionalresources for still more improvement. All the positive feedbacks that once actedas vicious cycles dragging reliability down become virtuous cycles, progressivelyand cumulatively boosting uptime and cutting costs.

Now the challenge facing the team was implementation. They knewnothing could happen without the willing participation of thousands of people,from the lowest-grade hourly mechanic to regional vice presidents. They alsorealized that their views had changed because they had participated in the

CALIFORNIA MANAGEMENT REVIEW VOL. 43. NO. 4 SUMMER 2001 83


modeling process. Somehow they had to facilitate a similar leaming processthroughout the plants.

The team convened the maintenance model into an interactive role-playing simulation they called the Manufacturing Game.'^ The game is closelybased on the tnodel and realistically captures the time delays, costs, and otherparameters characterizing typical plants. They embedded the game in an inter-active workshop designed to create an environment for learning that addressedemotional as well as cognitive issues. The process at Du Pont's WashingtonWorks complex in Parkersburg, West Virginia, was typical:

The team was initiated with a two-day leaming lab . . . learning the concepts ofdefect elimination and experiencing the Manufacturing Game. . . . The materialis presented in the form of lectures, skits and participative exercises in an off-siteenvironment. Posters and music are used. The atmosphere is much different thanroutine plant meetings or training, to open up their thinking Through inter-active exercises, the team develops their personal aspirations for improving thearea where they have chosen to work. . .. [Then] they .. . develop an actionplan to immediately start working.'*'

Despite its many simplifications, the game quickly becotnes in many ways areal plant with real emotions and conflicts among players. Initialized with highhreakdowns and low uptime, the people playing the role of operations managersface intense pressure to keep equipment running and often rebuff attempts toincrease planned maintenance, just as in the real world. Players who stick withthe prevailing cost-minimization, work-harder, reactive maintenance policiescan keep costs low for a while. However, as defects accumulate, uptime slowlysinks while costs rise. Teams who follow a planned maintenance strategy firstfind costs rise while uptime falls. Soon, however, costs begin to fall and uptimerises. The game allows people to experience the worse-before-better dynamic ina few hours instead of a few months. For many, the game was the first time intheir careers they experienced the possibility that improvement was actuallypossible.

The game and leaming laboratory proved popular. However, playing itonce was not enough. The team found that they had to run several workshopsfor a given plant before a critical mass emerged to lead action teams and putproactive maintenance policies into praaice. Individual plants needed the capa-bility to run the game so their own people, with their site-specific experienceand legitimacy, could run it on demand. By the end of 1992, some 1200 peoplehad participated in the workshop, and more than 50 facilitators had beencertified.

At plants that implemented the progratn by the end of 1993, the meantime between failure (MTBF) for pumps (the focus of the program) rose by anaverage of 12% each time cumulative operating experience doubled. Directmaintenance costs fell an average of 20%. In 23 comparable plants not imple-menting the program the leaming rate averaged just 5% and costs were up an

84 CAUFORNIA MANAGEMENT REVIEW VOL 43. NO. 4 SUMMER 2001


average of 7%. Washington Works boosted production capability 20%,improved customer service 90%, and cut delivery lead time by 50%, all withminimal capital investment and a drop in maintenance costs. For the companyas a whole, conservative estimates exceed $350 million/year in avoided mainte-nance costs alone.

However, success creates its own challenges. One issue related to thepersistence of the cost-saving mentality. A member of the modeling team com-mented, "As soon as you get the problems down, people will be taken awayfrom ihe effort and the problems will go back up." In fact, mandated corporatecost-cutting programs did cause significant downsizing throughout the entirecompany, weakening the reinvestment feedback and limiting their ability toexpand the program. Winston Ledet took early retirement and began workingwith other companies interested in the game and learning lab. These firmsinclude other chemicals manufacturers along with firms in the energy, auto-motive, and high-tech sectors.

British Petroleum

One of the organizations Ledet worked with after leaving Du Pontwas British Petroleum's refinery in Lima, Ohio. Founded in 1886 by John D.Rockefeller, and once "Queen of the Fleet," the refinery engaged in cost cuttingduring the 1980s that triggered the vicious cycle of increasing breakdowns,higher maintenance costs, and less planned maintenance, pushing it into thecapability trap. By the early 1990s, Lima lagged well behind other U.S. refiner-ies. BP began to think about selling or closing the facility.

In 1994, the Lima facility introduced the maintenance learning lab andother system dynamics tools. It was not a top management intervention: Theoriginal champions were an equipment specialist, a maintenance training super-visor, and an engineer. Successful pilot projects led to favorable word of mouth;eventually 80% of all employees participated in the program. Soon dozens ofimprovement teams were in place. During the first six months, maintenancecosts ballooned by 307o. Having experienced it in the game, management wasprepared for the worse-before-better dynamic, and focused on theimprovements generated by the action teams.

In January 1996, BP announced that it intended to sell the Lima refineryand stepped up its cost cutting and downsizing. A few months later BP stunnedthe employees by announcing that it could not lind a buyer at a satisfactoryprice and would therefore close the refinery. The announcement was a deepblow to the workers and the community. One of the most important businessesin the community, the refinery employed 450 people and pumped more than$60 million per year into Lima's depressed economy. Some employees becamediscouraged and questioned the value of the learning lab and improvement pro-gram. A few transferred to other BP facilities or left altogether. Winston Ledetdescribed what happened next:


Nobody Ever Gets Credft for Rxing Problems that Never Happened

T A B L E I . Improvement at the Lima Refinery

• Pump MTBF up from 12 to 58 months (failures down from more than 640 in 199 I to 131 in 1998).Direct savings: $ 1.8 million/year

• Hydrocarbon flare-off down from 1.5% to 0.35%, saving J0.27/barrel and improving environmentalquafity.

• On-line analyzer uptime improved from 75% and not trusted to 979o and trusted, permitting real-timeoptimization of product flow. Savings: $0,10-0.12/barrel.

• Safety incidents and lost hours cut by a factor of 4.

• Thirty-four production records set

• Cash nnargin improved by $0.77 per barrel of oil processed,

• Total new value created: $43 miliion/yearTotal cost $32O.OOO/year Ratio: 143:1.

• Learning initiative under way for other 8P facilities around the worid.

Source: Paul Monus. "Proactive Manufacturing at BP's Lima Oil Refinery," presented at National Petmleum Refiners Association

Maintenance Conference, May 20-23.1997, New Orleans j.Griffrth.D.Kuenzli, and RMonus,'"Proactive Manufadunng; Accelerating

Step Change Breakthroughs in Pefformance," NPRA Maintenance Conference, MC-9S-92,1998; Paul Monus, personal

communication.

"For those who decided to stay with the ship, a new spirit emerged. They realizedihat they needed a future in Lima and should take responsibility for creating thatfuture. The first step was lo ensure ihat the exit of many experienced people didnot throw them back in the reactive mode. . . . It actually created a clearer focusfor the people who remained. They were aU there because they had chosen to bethere.'

Soon the impaa of the new maintenance policies and attitudes was clearlyvisible (Table 1).

These dramatic improvements did not go unnoticed. On July 2, 1998,the banner headline of the Lima News announced "Oil Refinery Rescued." ClarkUSA, a privately held Fortune 500 company with refining and distribution inter-ests, agreed to buy the Lima refinery for $215 million and keep it operating.

The Du Pont and BP cases illustrate the power of a shift in mental models.The model, game, and workshop do not teach anyone how to maintain equip-ment. For example, a BP team reduced butane flare-off to zero, saving $1.5 mil-lion/year and reducing pollution. The effort took two weeks and cost $5000, areturn on investment of 30,000%/year. Members of the team had known aboutthe problem and how to solve it for eight years. They already had all the engi-neering know-how they needed, and most of the equipment and materials werealready on site. What had stopped them from solving the problem long ago? Theonly barrier was the mental model that there were no resources or time forimprovement, that these problems were outside their controL and that theycould never make a difference.

The modeling process and the resulting game were effective hecause theyeliminated many of the impediments to learning in the real system. Dynamics


Nobody Ever Gets Credit for Fixing PriDblems that Never Happened

such as the progressive slide into the capability trap that normally play out overyears or even decades could be experienced in just a few hours. Unlike the realworld, people could take different roles: A mechanic playing the role of plantmanager might find himself with low uptime and then cut preventive mainte-nance to avoid equipment takedowns and cut costs. Seeing people from differ-ent functions and backgrounds enacting the same behaviors helped break thevicious cycle of self-con firming attribution errors and blame. The systems think-ing process enabled people to experience for themselves the long-term, organi-zation-wide consequences of their actions. They discovered how to use initialsuccesses to create resources for funher improvement and how to survive theshort-run drop in performance. They saw how small actions could snowball intomajor gains. Most importantly, they learned that they could, after all, make adifference.

NotesSee G. Easton and S. Jarrell, "The Effects of Total Quality Management on Corpo-rate Performance: An Empirical Investigation," Journal of Business, 2 (1998): 253*307; K. Hendricks and V.R. Singhal, "Quality Awards and the Market Value of theFirm: An Empirical Investigation," Management Science. 43/3 (1996); 415-436.See Easton and Jarrell, op. cit.; Darrell Rigby, "Management Tools and Techniques:A Survey," California Management Review. 43/2 (Winter 2001): 1 39-159.See J. Pfeffer and R. Sutton, The Knowing-Doing Gap (Boston, MA: Harvard Busi-ness School Press, 2000): K. Klein and J. Sorra, "The Challenge of InnovationImplementation." Academy of Management Review. 4 (1996): IO55-1OSO.Published summaries can be found in: J. Sterman, N. Repenning, and F. Kt)linan'Unanticipated Side Effects of Successful Quality Programs: Exploring a Paradoxof Organizational Improvement," Management Science. 43/4 (1997): 503-521; N.Repenning and J. Sierman. 'Getting Quality the Qld Fashion: Selt-ConfirmingAttributions in the Dynamics of Process Improvement,' in R.B. Cole and R. Scott,eds., Improving Theory and Research on Quality Enhancement in Organizations (Thou-sand Oaks, CA: Sage, 2000), pp. 201- 235; E. Keating and R. Qliva, "A DynamicTheory of Sustaining Process Improvement Teams in Product Development," inM. Beyerlein and D. Johnson, eds.. Advances in Interdisciplinary Studies of Teams(Greenwich. CT: JAI Press, 2000); R. Qliva, S, Rockart, and J. Sierman, "ManagingMultiple Improvement Efforts: Lessons from a Semiconductor ManufacturingSite," in D. Fedor and S. Ghosh, eds.. Advances in the Management of OrganizationalQuality (Greenwich, CT: JAI Press. 1998), pp. 1-55; J. Carroll. J. Sterman. and A.Markus, "Playing the Maintenance Game: How Mental Models Drive Qrganiza-tion Decisions," in R. Stem and J. Halpern, eds.. Debating Rationality: NonrationalElements of Organizational Decision Making (Ithaca, NY: ILR Press. 1997).For formal models of implementation see: Sterman, Repenning, and Kofman op.cit.; N. Repenning, "Drive Out Fear (Unless You Can Drive It In): The Role ofAgency and Job Security in Process Improvement Efforts," Management Science.46/11 (2000): 1385-1396; N. Repenning, "A Dynamic Model of Resource Alloca-tion in Multi-Project Research and Development Systems," System DynamicsReview. 16/3 (2000): 173-212; N. Repenning. "A Simulation Based-Approach toUnderstanding the Dynamics of Innovation Implementation,' Organization Science(forthcoming).Repenning and Sterman (2000), op. cit.


Nobody Ever Gets Credft for Fixing Problems that Never Happened

7. See A. Schneiderman, 'Setting Quality Goals." Quality Progress (April 1988),pp. 55-57; J. Sterman, N. Repenning, and F. Kofman, op. dt.

8. Schneiderman, op. dt.9. For an example, sec Sterman, Repenning, and Kofman, op. dt.

10. The dynamics of project management and software development have beentreated extensively in system dynamics. See, for example, T. Abdel-Hamid, 'TheEconomics of Software Quality Assurance: A Simulation-Based Case Study,' MISQuarterly, 3 (1997): 395-411; D. Ford and J. D. Sterman 'Dynamic Modeling ofProdua Development Processes," System Dynamics Review. 14 (1998): 31-68.

11. For an excellent summary of aitribution theory, see S. Pious, The Psychology ofJudgment and Decision Making (New York, NY: McGraw-Hill, 1993).

12. See also George Roth and An Kleiner, Car Launch (New York, NY: Oxford Univer-sity Press, 2000).

13. See N. Repenning et al., "Past the Tipping Point: The Persistence of Fire-Fightingin Produa Development,' published in this issue [California Management Review.43/4 (Summer 2001)].

14. These cases are discussed In depth in J. Sterman, Business Dynamics: Systems Think-ing and Modeling for a Complex World {New York, NY: Irwin/McGraw-Hil!, 2000),chapter 2.

15. See Winston Ledet, 'Engaging the Entire Organization: Key to Improving Reiiabil-ity." Oil and Gas Journal. 97/21 (1999): 54-57.

16. R. Tewkshury and R. Steward, 'Improved Pruduaion Capability Program at DuPom's Washington Works," Proceedings of the 1997 Sodeiy for Maintenance andReliability annual conference.

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